In the early days when NHI was still being discussed at African National Congress headquarters, some trade unions made no secret of the fact that they wanted to get rid of the private sector, whether it be the providers or medical schemes.

However, several speakers at the HASA conference made it clear that they supported the principle of transforming the health system under the banner of NHI and that they felt they had a role to play.

One of Motsoaledi and his Director-General Precious Matsoso's biggest headaches is the management of hospitals.

And while the health department has some specific plans on how to deal with this headache, the question arises whether the private sector hospitals could play a meaningful role.

In an interview, Medi-Clinic group executive Roly Buys said that for a long time "everyone knew about NHI, but nobody knew about it".

He said that the Green Paper for the first time opened the door for them to enter the debate.

Buys said that private hospital groups such as Medi-Clinic had much to offer, including the training of people to manage and govern hospitals, over 20 years experience in patient administration systems, pharmacy management, managing patients and raising a bill, understanding disease patterns and so on.

"There are important decisions to be made on how we transfer these skills," said Buys.

He said that most of their hospital managers had been trained internally after building up a wealth of experience on the job and studying at tertiary level.

Asked whether he thought it was possible for the private sector and government to sit around a table, Buys said that Motsoaledi had been a breath of fresh air. "He is really dedicated to the task and entirely involved in his portfolio. But the problem he faces is so big and I am not sure he has the capacity in the public sector to deal with it. However, his vigor, interest, involvement and passion is very different from that of some of his predecessors. As long as there is consultation and robust debate I think we can go forward," said Buys, adding that the outlook was far more positive than a couple of years ago.

"There is a willingness on the side of the private sector to work, we want to find solutions," he said.

Buys said that in the short to medium term Medi-Clinic would want to address the huge shortage of nurses. "This is a critical area which affects both the private and public sector equally and we need to address these shortages urgently."

In terms of addressing the management of health facilities, Buys said Medi-Clinic would be more than willing to help set up the infrastructure to improve this sector.

Professor Lucy Gilson of the Health Economics Unit at the University of Cape Town responds to the questions whether the private sector had a role to play: "There are certainly lessons to be learnt about aspects of management, but we also need to acknowledge that managing public hospitals (as any public organisation), has some different and important dimensions because they work within complex bureaucratic settings, they seek to create public value rather than shareholder value, they serve a more heteregenous population with more heterogenous demands, are accountable to the population as citizens not just to their patients and so are subject to 'political' as well as technical lines of accountability."

Matsoso is adamant that the improvement of hospital management is critical and urgent.

She is currently toying with the idea of insisting that hospital managers need some formal qualification that is focused on management of health institutions.

"Over the years we have not been stringent in how we assigned people to these positions," she says.

Matsoso points out that significant revenue is lost by hospitals unable to collect money due to them. "You need competent managers to do this, but they also need to be given the responsibility and authority to do so," she adds. "Authority needs to be delegated to these managers."

She confirmed that part of the process will see current hospital managers re-applying for their jobs, but that "nobody will lose their job, they may be re-assigned".

Gilson lists a number of ways in which hospital management can be improved:

recruit leaders and managers with relevant experience and skills and a range of technical, general management and emotional competencies;

raise the profile of and acknowledge and value those who work in these vital positions, get people to choose leadership as a career and develop career paths for those in leadership positions;

enable them to strengthen competencies over time through continuous learning - forms of training that are rooted in real work place issues and problems, but also other forms of learning. They must also be able to share their experiences with each other, develop ideas through working with others and provide them with time and space to stand back from own experience and think about hew ways of doing things;

hold them accountable for their hospitals and their staff but use accountability frameworks as ways of supporting not just disciplining.

"One of South Africa's critical health care challenges is improving its responsiveness to population needs and expectations - and this requires the strengthening of leadership and governance across the health system. Public hospitals are particularly important because for the majority of the population they are commonly the first port of call when they are sick and vulnerable.

Hospital managers are not solely responsible for improving services at public hospitals but they can make an important difference. They must be recognised, along with other health managers, as the critical backbone of governance in the health system.

"Most are conscientiously and carefully managing often very difficult situations.

Whilst, like all health workers, they must be held accountable for their actions, they must also be acknowledged for the contributions they make in ensuring the health system serves the population. However, to be effective they need sufficient decision-making authority to be responsive to the particular needs of their organisation, as well as the guidance and support that will support them in their roles.

Also important are regular opportunities to share experiences and learn from each other, as well as refresh the wide range of technical, managerial and emotional competencies a strong leader requires. Public managers in general, and public hospital managers in particular, are vital in building a health system that serves all of the population in South Africa," said Gilson.

National Health Insurance NHI Love it or hate it It's coming With a Green Paper released for public consultation role players and South Africans at large for the first time have some concrete information as to how the South African healthcare landscape is going to be transformed However one of the early weaknesses identified in winning over South Africans to NHI is the lack of confidence in public health specifically public hospitals This means that improving public hospitals is a priority Private sector healthcare providers have been anxiously waiting to understand what their role is going to be with the health minister making ominous noises that the sector had to be regulated in an effort to curb the high cost of care Although Dr Aaron Motsoaledi is itching to curb the high cost of private health care he is under no illusion that he needs to partner with the private sector if NHI is to be successful The mood at the recent Hospital Association of South Africa conference was one of partnership and working together The theme w